[Association between body mass index and coronary heart disease in Qingdao: a prospective study].

Objective: To analyze the association between body mass index (BMI) and coronary heart disease. Methods: The data for the present study were from the prospective cohort study of China Kadoorie Biobank (CKB) in Qingdao, a total of 33 355 participants aged 30-79 years were included in the study. Cox regression analyses were performed to evaluate the association between BMI and coronary heart disease. Results: During the follow-up for an average 9.2 years, a total of 2 712 cases of ischemic heart disease (IHD) and 420 cases of major coronary events (MCE) were found. Multivariate Cox regression analysis showed that, compared with participants with normal BMI, the participants who were overweight had a 41% and 87% higher risk of IHD and MCE, the adjusted HR were 1.41 (95%CI: 1.27-1.56) and 1.87 (95%CI: 1.43-2.44), respectively. The participants who were obesity had 91% and 143% higher risk of IHD and MCE, the adjusted HR were 1.91 (95%CI: 1.72-2.13) and 2.43 (95%CI: 1.82-3.24), respectively. Conclusion: Overweight and obesity might increase the risk for IHD and MCE.

Bradykinin production and increased pulmonary endothelial permeability during acute respiratory failure in unanesthetized sheep.

To investigate mechanisms of pulmonary edema in respiratory failure, we studied unanesthetized sheep with vascular catheters, pleural balloons, and chronic lung lymph fistulas. Animals breathed either a hypercapnic-enriched oxygen (n = 5) or a hypercapnic-hypoxic (n = 5) gas mixture for 2 h. Every 15 min blood gases, pressures, cardiac output, lymph flow (Qlym), plasma and lymph albumin (mol wt, 70,000), IgG (mol wt, 150,000), IgM (mol wt, 900,000), and blood bradykinin concentrations were determined. In both groups, cardiac output and pulmonary arterial pressures increased, whereas left atrial pressures were unchanged. Acidosis alone (arterial pH = 7.16, PaCO(2) = 81 mm Hg, PaO(2) = 250 mm Hg) resulted in a doubling of lymph flow, a small increase in protein flux, and a decrease in lymph to plasma protein concentration (L/P) ratio for all three proteins. Acidotic-hypoxic animals (arterial pH = 7.16, PaCO(2) = 84 mm Hg, PaO(2) = 48 mm Hg) tripled Qlym. In these animals the increase in lymphatic flux of albumin, IgG, and IgM was significantly (P < 0.05) greater than that seen in either the acidosis alone group or in animals where left atrial pressures were elevated (n = 5; P < 0.05). Also, their percent increase in flux of the large protein (IgM) was greater than for the small protein (albumin) (P < 0.05). With acidosis alone, only pulmonary arterial bradykinin concentration increased (1.27+/-0.25 ng/ml SE), whereas acidosis plus hypoxia elevated both pulmonary arterial bradykinin concentrations (4.83+/-1.14 ng/ml) and aortic bradykinin concentration (2.74+/-0.78 ng/ml). These studies demonstrate that hypercapnic acidosis stimulates in vivo production of bradykinin. With superimposed hypoxia, and therefore decreased bradykinin degradation, there is an associated sustained rise in Qlym with increased lung permeability to proteins.

Experimental coronary arterial occlusion and release. Effects on enzymes, electrocardiograms, myocardial contractility and reactive hyperemia.

After less than 1 hour of coronary arterial occlusion, the myocardium suffers irreversible changes as revealed by electron microscopy. Yet, the earliest clinical laboratory indexes of myocardial infarction--elevated serum enzyme levels and significant Q waves on the electrocardiogram--are not detected until at least 6 hours after coronary occlusion. To study the early period after coronary occlusion in the dog, occlusion of the left anterior descending coronary artery for 1 to 3 hours was followed by release, and coronary sinus and venous enzyme levels, the electrocardiogram and myocardial contractility from the infarcted area, and reactive hyperemia were monitored. Coronary sinus enzyme levels rose within 15 minutes after release of occlusion in half of the experiments with 1 to 1 1/2 hours and in all of those with 2 to 3 hours of occlusion, and this rise preceded the rise in venous levels by only 10 to 20 minutes. Significant Q waves appeared 15 to 30 minutes after release of occlusion as the serum enzymes were increasing. Thus, clinically, the delayed appearance of increased serum enzymes and significant electrocardiographic Q waves is probably largely due to a lack of circulation in the infarcted area rather than to prolonged survival time. Also, the venous enzyme level reflects the coronary sinus level minutes later. The presence of viable myocardium in the infarcted area was suggested by elevation of the S-T segment upon reclamping, and by residual myocardial contractility and retained capacity for reactive hyperemia. These findings occurred in some experiments even in the presence of a significant Q wave.

Terbutaline in the treatment of status asthmaticus.

The effect of administration of terbutaline on the pulmonary and cardiovascular systems was studied in ten children with status asthmaticus. Terbutaline (0.01 to 0.04 mg/kg of body weight) was given subcutaneously in multiple doses. A significant decrease in respiratory rate and in arterial blood pressure, with no significant change in cardiac rate, was seen only after the first dose of terbutaline. There was a decrease in mean arterial carbon dioxide tension and an increase in mean arterial oxygen pressure. There was gross clinical improvement following administration of terbutaline in nine of the ten patients. One patient who failed to respond to administration of terbutaline also failed to respond to intravenously administered isoproterenol. We conclude that terbutaline is effective in the treatment of status asthmaticus, with only modest effects on the cardiovascular system.

Terbutaline in the treatment of acute asthma in childhood.

Forty-eight children with known asthma (ranging in age from 2 to 16 years) were studied during an acute attack. Each received either terbutaline or epinephrine subcutaneously in a random double-blind fashion. Measurement of heart rate, respiratory rate, and systemic arterial systolic and diastolic blood pressures and careful clinical assessment of obstruction of the airway were made before and at 15, 30, and 60 minutes after the administration of the drugs. Appreciable and significant clinical improvement was noted in 19 of the 24 patients in both groups and was of comparable magnitude. A small, but significant, increase in heart rate was noted in those patients requiring only one injection of terbutaline, suggesting that the drug's selectivity for the lung is relative not absolute. The present study demonstrates that terbutaline is an effective bronchodilator drug in acute childhood asthma.

Ductal carcinoma in situ arising in mammary hamartoma.

Hamartoma of the breast is an uncommon lesion. Although it can possess characteristic radiological features, the pathological appearance is not distinctive. Hamartoma is generally considered benign, but four cases have been reported with ductal and lobular carcinoma arising in hamartomas. This report describes further cases of hamartoma from which ductal carcinoma in situ arose, with one showing early invasion. In both cases, the tumours were within the hamartomas and were adequately excised during lumpectomies of the hamartomas, and the patients were well afterwards. This report emphasises the importance of adequate sampling of mammary hamartoma.

Fine needle aspiration cytology of granulomatous mastitis.

AIMS: Granulomatous mastitis (GM) is an uncommon breast lesion that mimics carcinoma. The fine needle aspiration cytological (FNAC) features of GM have rarely been discussed in the literature. These features are reported in eight histologically confirmed cases of GM. METHODS: A retrospective study was undertaken in which a diagnosis of GM had been made on histopathology, and the FNAC slides were reviewed and assessed for the presence of granulomas, necrosis, multinucleated giant cells, and inflammatory background cells. Polymerase chain reaction (PCR) for Mycobacterium tuberculosis was performed on the histological material to exclude tuberculosis. RESULTS: All cases were confirmed histologically and PCR for mycobacterial DNA was negative. In the FNACs, varying numbers of granulomas composed of epithelioid histiocytes were present in four cases. The same four cases showed giant cells of either foreign body or Langhan's type. No necrosis was noted. Six cases showed many histiocytes, some plump and others epithelioid, in the background. The number of epithelioid histiocytes corresponded to the presence of granulomas. Neutrophils were the predominant background inflammatory cells in most cases (six). CONCLUSIONS: The cytological diagnosis of GM is difficult because the features overlap with other aetiologies, including tuberculosis. Specific features are absent. The absence of necrosis and a predominantly neutrophilic infiltrate in the background favour a diagnosis of GM. This diagnosis should also be considered when abundant epithelioid histiocytes are seen in smears, even in the absence of granulomas. However, the definitive diagnosis of GM depends on histology from fine needle biopsies and negative microbiological investigations.

Hamartoma of the breast: a clinicopathological review.

AIMS: To review 25 cases of breast hamartoma and discuss the pathological criteria, and the usefulness of imaging modalities, fine needle aspiration cytology (FNAC), and needle core biopsy in the diagnosis. METHODS: The hamartomas were assessed for interlobular fibrotic stroma, stromal adipose tissue content, pseudo-angiomatous stromal hyperplasia, and epithelial changes (hyperplasia, adenosis or apocrine metaplasia, and cyst formation). All imagings, previous FNACs, and biopsies were also reviewed. RESULTS: Imaging (mammography, ultrasound, and magnetic resonance imaging) was performed in 18 cases, and mostly showed encapsulated masses with a heterogeneous appearance. Microscopically, all hamartomas demonstrated good demarcation with fibrous tissue condensation. Adipose tissue was noted in all cases (5-90%; mean, 31%), and interlobular fibrosis in 21 cases. Benign epithelial hyperplasia occurred in 10 cases, and pseudo-angiomatous stromal hyperplasia or cystic ducts in eight cases each. Apocrine metaplasia, calcification, stromal giant cells, and adenosis occurred in four cases or less. Two cases showed coexisting ductal carcinoma in situ limited to within the hamartoma. Needle core biopsies (four cases) and FNAC (14 cases) were largely insufficient, inconclusive, or non-specific. CONCLUSIONS: Hamartomas do not possess specific diagnostic histological features. The role of FNAC and needle core biopsy in making the diagnosis is limited, and requires clinical and radiological correlation to avoid underdiagnosis.

Blood flow to respiratory muscles and major organs during inspiratory flow resistive loads.

To determine whether diaphragmatic fatigue in the intact animal subjected to loaded breathing is associated with a decrease in diaphragmatic blood flow, seven unanesthetized sheep were subjected to severe inspiratory flow resistive (IFR) loads that led to a decrease in transdiaphragmatic pressure (Pdi) and a rise in arterial PCO2 (PaCO2). Blood flow to the diaphragm, other respiratory muscles, limb muscles, and major organs was measured using the radionuclide-labeled microsphere method. With these loads blood flow increased to the diaphragm (621 +/- 242%) and all the other inspiratory and expiratory diaphragm (621 +/- 242%) and all the other inspiratory and expiratory muscles; there was no statistically significant change in blood flow to these muscles at the time when Pdi decreased and PaCO2 rose. Blood flow also increased to the heart (103 +/- 34%), brain (212 +/- 39%), and adrenals (76 +/- 9%), whereas pancreatic flow decreased (-66 +/- 14%). Limb muscle blood flow remained unchanged. We conclude that in unanesthetized sheep subjected to IFR loads 1) we did not demonstrate a decrease in respiratory muscle blood flow associated with diaphragmatic fatigue and ventilatory failure, and 2) there is a redistribution of blood flow among major organs.

O2 metabolism of the sheep diaphragm during flow resistive loaded breathing.

To determine whether O2 availability limited diaphragmatic performance, we subjected unanesthetized sheep to severe (n = 11) and moderate (n = 3) inspiratory flow resistive loads and studied the phrenic venous effluent. We measured transdiaphragmatic pressure (Pdi), systemic arterial and phrenic venous blood gas tensions, and lactate and pyruvate concentrations. In four sheep with severe loads, we measured O2 saturation (SO2), O2 content, and hemoglobin. We found that with severe loads Pdi increased to 74.7 +/- 6.0 cmH2O by 40 min of loading, remained stable for 20-30 more min, then slowly decreased. In every sheep, arterial PCO2 increased when Pdi decreased. With moderate loads Pdi increased to and maintained levels of 40-55 cmH2O. With both loads, venous PO2, SO2, and O2 content decreased initially and then increased, so that the arteriovenous difference in O2 content decreased as loading continued. Hemoglobin increased slowly in three of four sheep. There were no appreciable changes in arterial or venous lactate and pyruvate during loading or recovery. We conclude that the changes in venous PO2, SO2, and O2 content may be the result of changes in hemoglobin, blood flow to the diaphragm, or limitation of O2 diffusion. Our data do not support the hypothesis that in sheep subjected to inspiratory flow resistive loads O2 availability limits diaphragmatic performance.

Neonatal surgical emergencies.

Improvements in the diagnosis and treatment of congenital disorders have resulted in a change in surgical practice. Many conditions that formerly required corrective surgery immediately after birth are no longer surgical emergencies. Most babies with congenital anomalies that can be corrected by surgery are now stabilized and optimized before the procedure. This article focused on the more common conditions that require semi-elective or urgent surgery in the neonatal period. Salient features of each of these disorders were described. Factors unique to each of these conditions that can affect the anesthetic course of these children were discussed. Methods and techniques that may aid in the anesthetic management of these children were delineated.

Effect of acute lymphatic obstruction on fluid accumulation in the chest in dogs.

The effect of acute obstruction to lymphatic drainage on fluid accumulation in the lungs, pleura, and pericardium was assessed in the intact dog. Catheters were positioned in the venae cavase, right atrium (RA), left atrium (LA), age on fluid accumulation in the lungs, pleura, and pericardium was assessed in the intact dog. Catheters were positioned in the venae cavae, right atrium (RA), left atrium (LA), and aorta (Ao) of nine anesthetized, spontaneouly breathing dogs, and hydrostic and colloid osmotic pressures were continuously monitored. Lymphatic obstruction was achieved by raising systemic venous pressure to either 10 mmHg or 25 mmHg by a combination of fluid infusion and inflation of balloon catheters in the venae cavae for 2 h. The same constant net intravascular filtration pressure was maintained in both groups by appropriate use of saline or colloid-containing fluids. Pleural and pericardial fluids were measured postmortem and lung water content was determined by weighing before and after drying. Failure to detect greater fluid accumulation at the higher obstructing pressure (25 mmHg) than at the lower obstructing pressure (10 mmHg) suggests that over the range of obstructing pressures used there is no acute change in the magnitude of lymphatic drainage in the chest.

Desferrioxamine-induced long bone changes in thalassaemic patients - radiographic features, prevalence and relations with growth.

AIM: To study the radiographic findings of desferrioxamine-induced bone dysplasia, its prevalence and relation to growth in thalassaemic patients. MATERIALS AND METHODS: A cross-sectional study was performed in 35 thalassaemic patients on a hypertransfusion scheme and chelation therapy at a dose not exceeding 50 mg/kg/day. Radiographs of the left hand taken for bone age assessment in consecutive patients over the past 12 months were evaluated for signs of desferrioxamine-induced bone dysplasia. The findings were correlated with data on growth, chelation and body iron content. RESULTS: Twelve of 35 patients had evidence of desferrioxamine-induced long bone dysplasia. There was no significant difference in the groups with and without radiographic evidence of bone dysplasia with respect to the height percentile at time of initiation of therapy, height percentile at time of radiography, skeletal age delay, age at starting chelation, chelation dose and duration, units of blood transfused, average chelation dose, and serum ferritin levels at time of radiography. Both groups showed a reduced percentile growth with a significantly greater reduction (P = 0.03) in the patients with dysplastic change. CONCLUSION: Desferrioxamine-induced bone dysplasia is associated with height reduction and can be seen in patients receiving desferrioxamine chelation therapy at doses of less than 50 mg/kg/day. Awareness of the diagnosis is of importance as reduction of the desferrioxamine dose may improve bone growth.

Effect of hyperinflation and atelectasis on fluid accumulation in the puppy lung.

The effects of hyperinflation and of atelectasis on accumulation of fluid in the lung was studied in 12 anesthetized spontaneously breathing puppies. Vascular pressures were raised and the plasma colloid osmotic pressure was reduced by the infusion of 0.9% saline thus promoting the formation of pulmonary edema. A tracheostomy was performed and the left lower lobe catheterized in all puppies. In five puppies hyperinflation of the left lower lobe was achieved by applying a continuous positive airway pressure (CPAP) of 10 Torr. In seven other puppies the left lobe was made atelectatic by occluding its bronchus after ventilating the lungs with 100% oxygen. The right lung was ventilated to ambient pressure in all puppies. The extravascular lung water content was determined by the difference in wet and dry lung weights corrected for residual blood. We found that hyperinflation produced by CPAP enhanced and atelectasis opposed fluid accumulation in the puppy lung.

Bradykinin-induced increase in pulmonary vascular permeability in hypoxic sheep.

Bradykinin (BK) is a potent edematogenic agent in systemic tissues. It is degraded by angiotensin-converting enzyme (ACE), which is located on the surface of all vascular endothelia. We hypothesized that since oxygen tension modulates ACE activity, the high pulmonary oxygen tension and hence high ACE activity protects the lung from the edematogenic effects of BK. We therefore studied the effect of exogenous BK in unanesthetized sheep with surgically created lymph fistulas and vascular catheters during normoxia and hypoxia. BK significantly elevated lung lymph flow and protein flux only when the sheep were made hypoxic and the lung's ability to degrade BK was impaired. This increase could not be attributed to recruitment of vascular surface area or to an increase in the driving force for fluid exchange because there were no changes in pulmonary arterial or left atrial pressures, cardiac output, or pulmonary vascular resistance. We conclude that BK increases water and protein movement in the lung by increasing vascular permeability.

Hemodynamic and vasoactive mediator response to experimental respiratory failure.

We determined the changes in hemodynamics and circulating concentrations of endogenous vasoactive mediators during acute respiratory failure in chronically catheterized unanesthetized sheep. Inhalation of a hypercarbic-hypoxic gas mixture for 2 h (pHa = 7.16, PaCO2 = 84 Torr, PaO2 = 48 Torr, n = 5) resulted in a doubling of cardiac output (thermodilution) and systemic and pulmonary hypertension. Systemic vascular resistance decreased, whereas pulmonary vascular resistance gradually increased throughout the 2-h experimental gas period. Pulmonary hypertension persisted for 45 min after return to room air breathing. Plasma renin activity tripled, and circulating bradykinin concentration increased 25-fold (radioimmunoassay). Plasma norepinephrine and epinephrine concentrations (radioenzymatic assay) dramatically increased with respective initial values (15 min) of 23.9 +/- 9.5 (SE) and 26.7 +/- 13.3 ng/ml (base line less than 0.2). Inhalation of hypoxic (n = 4) or hypercarbic-enriched O2 (n = 7) gas mixtures did not produce similar findings. We concluded that the hemodynamic response to experimental respiratory failure results from the combination of hypercarbic acidosis and hypoxia. These changes were mediated in part by increased sympathoadrenal activity and altered concentrations of H+, O2, and endogenous vasoactive mediators.

Sellar and suprasellar medulloepithelioma.

Medulloepithelioma is a rare tumour with a very poor prognosis. The most frequent site in the central nervous system is the cerebral hemispheres. Appearances on MRI are very variable, possibly reflecting the divergent forms of differentiation seen at histological examination. We report a rare case of sellar and suprasellar medulloepithelioma in a 2-year-old boy and discuss the imaging, differential diagnosis and pathologic findings.